Measure Type: Process- High Priority Description: Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.

CPT Codes:

Denominator note: *Signifies that this CPT Category I code is a non-covered service under the PFS (Physician Fee Schedule). These non-covered services will not be counted in the denominator population for claims-based measures.

Diagnosis Codes:

CMS has stated that ICD-10 should be coded to the greatest specificity and unspecified codes may be denied. Therefore the codes listed below with a strikethrough should not be included on your claim or submitted with this quality measure.

Claims based and IRIS Registry Manual Reporting

Category II and HCPCS Codes:

Note: There are four options for reporting this measure. Each requires a Category II code and one HCPCS G code.

5010F Findings of dilated macular or fundus exam communicated to the physician managing the diabetes care; andG8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy;

or

5010F 1P Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the on-going care of the patient with diabetes and G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy

or

5010F 2P Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the on-going care of the patient with diabetes and G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy , orG8398 Dilated macular or fundus exam not performed.

or

5010F 8P Findings of dilated macular or fundus exam was not communicated to the physician managing the diabetes care, reason not otherwise specifiedandG8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy

IRIS Registry EHR Reporting

Instructions: Percentage of patients 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam within 12 months.

These are the required elements to be documented at least once a year to meet the measure performance requirements.

Evidence of a letter or call to the physician documenting severity of diabetic retinopathy and presence or absence of macular edema

Severity of diabetic retinopathy:

Mild NPDR

Moderate NPDR

Severe NPDR

Very Severe NPDR

Proliferative DR

Presence or absence of macular edema

How CMS Scores Your Performance

If you report this measure for at least 50 percent of applicable patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.

If you successfully report a measure for less than 50 percent of your patients, you will earn 3 points.

You can also earn bonus points because of the measure type and if you electronically report this measure (i.e., through an integrated EHR system).